Pharm 201 Chapter 49
The nurse is assigned to perform telephone triage for the clinic and receives a call from a young mother whose 6-month-old baby received her third diphtheria-pertussis-tetanus immunization that morning. The mother reports the baby's temperature is 99.8° axillary, the site of injection is "a little red," and the baby is irritable. After checking the standing orders provided by the pediatrician, what teaching would the nurse provide this mother? Select all that apply.
"These are common adverse effects reported after immunizations." "Apply a warm moist compress to the baby's leg." "Symptoms should subside within 2 to 3 days."
A primiparous woman tells the nurse that she and her partner are highly reluctant to have their infant vaccinated, stating, "We've read that vaccines can potentially cause a lot of harm, so we're not sure we want to take that risk." How should the nurse respond to this family's concerns?
"Vaccinations are not without some risks, but these are far exceeded by the potential benefits."
A neonate who weighs 7 lbs, 8 oz kg is prescribed the hepatitis B immune globulin at a dose of 0.06 mL/kg IM. To one decimal place, what dose should the nurse administer?
.2
The nurse is teaching a course to students about immunologic agents. In order for the students to understand active immunity, the nurse explains that there are agents that provide active immunity. Which is an active immunity agent?
Haemophilus influenzae type B conjugate
Which would a nurse expect to administer to a client who has not been immunized and has sustained a bite from an animal with rabies?
Immune globulin
The nurse is caring for a 16-year-old client who just received a kidney transplant. Which of the following passive immunity agents would the nurse include in the family teaching session regarding prevention of organ rejection?
Immune globulins
A mother has brought her infant to the clinic for the first immunization. What would the nurse be sure to include when providing education for the infant's mother?
Keep a written record of the child's immunizations.
A client has presented to the clinic and is requesting the seasonal influenza vaccine. What aspect of the client's health history may contraindicate the safe and effective use of this vaccine?
The client is current prescribed prednisone
A public health nurse is responsible for the administration of immunizations. Which guideline regarding anaphylaxis should the nurse adhere to?
The client should be observed for anaphylaxis for 30 minutes after administration.
A landscaper has sought care because of a puncture wound to her foot and the provider has prescribed 250 units of the tetanus immune globulin. In preparation for administration, the nurse should:
assess the skin integrity of potential intramuscular injection sites.
The nurse is working with an 18-year-old client who recently immigrated and who did not receive childhood immunizations. The client is "catching up" on immunizations and is scheduled to receive a measles, mumps and rubella (MMR) vaccine today. What should the nurse teach the client about potential adverse effects?
"You might feel a bit unwell or get a slight fever after receiving your immunization."
A client, aged 72, is brought to the clinic by her daughter. The daughter asks how often her mother should receive the influenza vaccine. What would be the nurse's best response?
"Your mother needs the influenza vaccine yearly."
A mother brings her 18-month-old into the clinic for a well-baby check-up. A nurse will administer measles, mumps, and rubella vaccine (MMR) to the 18-month-old. What dosage will the nurse administer?
0.5 mL IM
The onset of protection after the administration of an immune globulin to a client is rapid but its duration is short, typically which time frame?
1 to 3 months
A mother brings her 18-month-old son into the clinic for his diphtheria, tetanus, and pertussis vaccine. The child has a runny nose and a fever of 102.4º F and is coughing. What should the nurse do?
Instruct the mother to bring the child back to the clinic for the immunization when he is free of allergic or cold-like symptoms.
The nursing instructor is explaining the best way to assess whether active immunity has developed from the administration of the hepatitis B series. What would the instructor cite as the best assessment method?
Serum antibody levels
A 45-year-old female client is being seen at the oncology clinic for a two-year follow up for cancer. Within the past two days, the client was exposed to hepatitis A and requests immune globulin prophylaxis. The nurse checks the electronic health record and discovers the client has had extensive immunosuppressive drug therapy in the past. The nurse knows that the client's history guides the nurse to take which of the following actions?
Teach the client that the administration of immune globulin is contraindicated for clients with a history of immunosuppressive drug therapy and leukemia.
A clinic nurse is administering vaccines at well-baby check-ups. The nurse knows that before administering a DTP vaccine, the nurse should check what vital sign?
Temperature
When providing client teaching to parents regarding measles, mumps, and rubella vaccine administration, which is most important regarding the schedule for administration?
It is administered at 12 to 15 months.
The nurse is preparing to administer a vaccine to a newborn. Before administering the vaccine, the nurse should:
check the infant's temperature.
A client is scheduled to receive an immunization. In which client may the administration of a live vaccine be contraindicated?
client taking steroid therapy
A child 10 years of age was bitten on the left hand by a Mojave rattlesnake one hour ago, and his left hand, arm, and chest are swollen. When providing information about the treatment to the parents of the child, the nurse would include which of the following statements?
"Antivenins are most effective in treating snake bites when the drug is administered in the first four hours after the bite."
Which statement indicates that an older adult client correctly understands the current recommendations concerning tetanus-diphtheria booster vaccinations?
"I know that this booster is good for 10 years."
A client prescribed prednisone 40 mg daily should be provided what information about immunizations by the nurse?
"You should wait at least 3 months after chemotherapy to obtain a live vaccine immunization."
The nurse is explaining a schedule for vaccinations to the parents of a new client. When would the nurse explain that the measles, mumps, and rubella (MMR) vaccine is initially administered?
15 months
The nurse should be prepared to administer an infant's first dose of polio vaccine at what age?
2 months
The nurse understands that administration of the routine and booster vaccines are indicated for immunization against polio in which of the following age groups? Select all that apply.
2 months 4 months 6 months
If a nurse is administering immune globulin to a client in the health care provider's office, the nurse would monitor the client for hypersensitivity reactions for how long after administering the drug?
30 minutes
A client bitten by a copperhead snake will benefit the most if the antivenin is administered within how long after exposure?
4 hours
A client has presented to the emergency department with a puncture wound suffered a few hours ago while demolishing an old house. The nurse's assessment reveals that the client is not in acute distress. The client's immunization status is unknown. What intervention should the nurse prioritize?
Administering tetanus immune globulin as prescribed
What client would be most likely to benefit from the administration of an antitoxin?
A client in distress who is showing signs and symptoms of botulism
The nurse at an ambulatory clinic has seen several clients with suspected or confirmed infectious diseases in recent days. Which client is most likely to benefit from the administration of an immune serum.
A client who is known to have contracted hepatitis B from sexual activity
The infection control nurse is assessing the immunization status of many of the hospital's current clients. For what client would vaccination most likely be contraindicated?
A client who takes immunosuppressants post-renal transplant
he nurse explains the purpose of vaccines is to promote what? Select all that apply.
Active immunity Lifetime immunity Activation of the immune system
A hospitalized client is about to receive immunological therapy and asks the nurse to explain the difference between passive and active immunity. In order to provide complete information, the nurse knows to include which information during the teaching session?
Active immunity occurs when a client receives a killed or weakened antigen that stimulates antibodies. These antibodies fight the antigen (for example, chickenpox vaccine).
A group of students are role playing various scenarios related to biological weapons. In one of the situations, an adult client develops botulism. What is the appropriate choice for treatment?
Antitoxin
The administration of immunizations to a client is a form of what type of immunity?
Artificial active immunity
The nurse at the pediatric clinic gives the mother of an infant a written record of the infant's immune sera use. The nurse encourages the mother to keep the information. What is the rationale behind keeping a written record of immune sera use?
Avert future reactions
An adult client being treated for breast cancer inquired about required vaccinations. What information should the nurse provide to this client?
Avoid all live vaccines.
The nursing students are learning about childhood vaccinations. What would they learn is the recommended childhood and adolescent immunization schedule for measles, mumps, and rubella (MMR)?
Between 12 and 15 months and between 4 and 6 years
A nurse is receiving post-exposure prophylaxis for hepatitis B. What would the nurse most likely receive?
Immune globulin
A young mother asks the clinic nurse about the "chickenpox" vaccine. The mother states that she and her husband have both had chickenpox, but that she wants to protect her child if she can. What should the nurse tell the mother about the recommendation for the chickenpox vaccine?
It is recommended for all children who have not been exposed to the varicella virus.
An infant is being administered an immunization. Which statement provides an accurate description of an immunization?
It is the administration of an antigen for an antibody response.
The nurse is teaching the parents of a child who has received immunizations and possible adverse effects. What would the nurse identify as common adverse effects? (Select all that apply.)
Nodule at the injection site Fretfulness Chills Anorexia
An male 18 years of age is brought to the clinic by his coach. The football coach tells the nurse that a member of the team has been diagnosed with hepatitis A and that this student was exposed five days ago. What nursing action is indicated after the administration of IGIV?
Observe the student for 30 minutes in the school clinic for hypersensitivity reaction.
When discussing vaccines in class, a student asks the instructor what an antitoxin is? What is an example of an antitoxin?
Passive immunity
The nursing instructor is discussing immunity with the clinical group. What statement would the instructor make that would be an accurate statement concerning immunity?
Passive immunity is limited.
Which statement should the nurse include in a discussion about passive immunity?
Passive immunity provides temporary protection from disease.
A nurse is participating in an influenza vaccination clinic on a college campus. What action will best prepare the nurse for this role?
Review the procedure for intramuscular injection
The college health nurse is providing health education for freshmen. Which piece of information about immunizations is applicable to individuals of this age group?
The yearly administration of flu vaccine is recommended.
A nurse is teaching a group of clients about immunizations . What benefit of immunization should the nurse describe?
They provide the person with active immunity.
What is the difference between toxoids and vaccines?
Toxoids always require occasional boosters
Booster doses are given to help further stimulate antibody formation after a vaccine is initially given.
True
To prevent chickenpox, a client would receive a viral vaccine.
True
The difference between toxoids and vaccines is:
Vaccines induce antibody formation, which prevent the disease or cause a very mild form. Many vaccines produce long-lasting immunity. Toxoids are bacterial toxins or products modified to destroy toxicity. Toxoid immunization is not permanent; scheduled repeat doses (boosters) maintain immunity.
he difference between toxoids and vaccines is:
Vaccines induce antibody formation, which prevent the disease or cause a very mild form. Many vaccines produce long-lasting immunity. Toxoids are bacterial toxins or products modified to destroy toxicity. Toxoid immunization is not permanent; scheduled repeat doses (boosters) maintain immunity.
A new nurse is preparing to administer Zovirax ointment to a client who has been diagnosed with varicella zoster. The nurse knows that which administration instruction is important for the client to follow?
Wear gloves when applying the ointment.
An older adult client has been brought to the clinic by family members who are concerned about the client's risk for developing shingles. The nurse should discuss what possible vaccination?
Zoster vaccine
What would contraindicate the administration of scheduled immunizations at a client visit for a 6-month-old infant?
a low-grade fever
A female health care worker has received her annual influenza vaccination and has remained at the clinic after administration so that the nurse may observe for adverse reactions. The worker reports pain at the site of IM injection. What should the nurse recommend?
acetaminophen
What recommendation concerning vaccinations should the nurse provide a 50-year-old adult?
annual influenza vaccination
The nurse has just administered the measles, mumps, and rubella vaccine to a female client. The nurse instructs the woman to avoid becoming pregnant for how long?
at least 3 months
A nurse is educating a group of nursing students about the different types of vaccines. Which should the nurse mention as a killed virus vaccine?
influenza vaccine
When educating clients on the immune system, the nurse identifies which white blood cells to be involved in cell-mediated immunity (CMI) along with T lymphocytes?
macrophages
A client about to receive an injection of influenza vaccination should be informed of the possibility of experiencing which short-term adverse effect? Select all that apply.
malaise muscle aches low-grade fever erythema at the injection site
When teaching new parents about the benefits of adhering to the recommended vaccination schedule for their infant, the nurse should cite protection against which diseases? Select all that apply.
measles varicella poliomyelitis hepatitis B
A nurse is providing education to the mother of a child receiving their first immunization. The nurse tells the mother that after the injection it is normal for the child to have:
pain, redness, and swelling at site of injection.
The administration of immune globulins or antivenins to a client is a form of what type of immunity?
passive immunity
A nurse is educating a group of nursing students about the contraindications of human immune globulin. Which would the nurse include? Select all that apply.
preexisting renal disease age more than 65 years diabetes mellitus
A client has received a rubella immunization. The client was unaware that she was pregnant. What risk is associated with the administration of the rubella immunization in this client?
risk of birth defects
A client with a history of multiple drug allergies is scheduled to receive a vaccination against chickenpox. Which would the nurse expect to be completed before the vaccine is administered?
skin test
A client is scheduled to receive an immunization. Administration of live vaccine is contraindicated in the client with:
steroid therapy.
A clinic nurse is administering vaccines during well-baby visits. The nurse knows that before administering a DTP vaccine to a child, the nurse should assess the child's:
temperature.
When instructing the parents of a child who has received immunization in the vastus lateralis, which reaction is most common in the days after the administration?
tenderness and redness at the site
Middle-aged adults and health care workers should receive which collection of immunizations?
tetanus-diphtheria-pertussis, hepatitis B vaccine once, and influenza vaccine annually
When describing cell-mediated immunity, a nurse would explain that this type of immunity depends on which response or action?
the action of T lymphocytes
A client being vaccinated for measles asks the nurse about the contents of the vaccine. During the explanation, the nurse mentions a poisonous substance produced by some bacteria that is capable of stimulating antitoxin production. Which is the nurse referring to in the explanation?
toxin
When providing a health promotion presentation to a group of seniors, how often should the nurse instruct the senior group to obtain influenza vaccines?
yearly
A 70-year-old client is seen in the family practice clinic. Which vaccine should be administered to prevent herpes zoster?
zoster vaccine
A client is undergoing a yearly physical. While discussing immunizations, the client states not wanting any immunizations because they can cause diseases. The nurse's best response is:
Immunizing agents are quite safe, and risks of the diseases they prevent are greater than the risks of the vaccines.
Which response best demonstrates a nurse's understanding of the risk immunizations pose concerning the development of resulting illness?
"Immunizing agents are quite safe, and risks of the diseases they prevent are greater than the risks of the vaccines."
The nurse is caring for a 30-year-old woman who came to her gynecologist today to receive a Gardasil injection, stating that she believes that she may have genital warts. What should the nurse teach this client?
"The drug is only effective if administered before exposure to human papillomavirus (HPV)."
A parent has contacted the nurse and is concerned about media reports of a measles outbreak. The parent's child is 9 months old and is wanting to confirm that the child has been immunized against measles. How should the nurse best respond?
Fifteen months is the youngest age at which the child should be vaccinated
The school nurse is addressing a parents' group and is discussing an upcoming campaign of human papillomavirus (HPV) vaccination. What should the nurse teach this group of parents?
HPV vaccination is recommended for both boys and girls
A school nurse at a large high school is attempting to determine correct vaccine guidelines. What is the best source for current recommendations?
Centers for Disease Control and Prevention
It is important for the nurse to stay current with the recommendations for immunizations. Which source is most accurate regarding immunization guidelines?
Centers for Disease Control and Prevention
An order for a PCR confirms that for a client that the painful rash on her trunk is caused by herpes zoster (shingles). The nurse explains that the painful rash is called shingles and is caused later in life by which of the following infections?
Chickenpox
The nurse educator is teaching a class of community leaders about immunologic agents. To minimize the concern regarding adverse effects of vaccinations, the nurse should include which mild reactions in the teaching plan?
Chills and fever
The elderly client returns from a health care visit and asks the nurse why another flu shot was necessary this year because the client got one last year. The nurse's best response is:
Each year a new vaccine is developed based on the strains most prevalent.
Upon which statement should the nurse base his or her response to an older client who questions the need for yearly flu vaccinations?
Each year a new vaccine is developed based on the strains most prevalent.
An immunocompromised client is exposed to hepatitis A. The health care provider orders an injection of immunoglobulin as prophylaxis against the hepatitis A. What adverse effects would the nurse advise the client might occur? (Select all that apply.)
Fever Angioedema Urticaria
A group of nursing students are presenting information on the hepatitis B vaccine. What would the students prepare to tell others about the recommended population?
Infants and people at risk for contracting the disease
A 1-year-old child will receive her scheduled MMR vaccination shortly. The nurse should teach the child's parents that the child may develop what possible adverse effect related to the administration of this medication?
cough and fever
